<html>
 <head>
  <title>Readmission Risk</title>
 </head>
 <body>

<!--change action if we are using a different page for displaying the patient history table-->
<form action="index.php" method="post"> 
   Patient Name: <input type="text" size="20" name="pname"><br>
   Gender: <select name="gender">
   <option value="M">Male</option>
   <option value="F">Female</option>
   </select><br>
   Patient Age: <input type="text" size="20" name="page"><br>
   Primary Diagnosis: <select name="pdis">
   <option value="123">Heart Disease</option> 
   <!--value should match diagnosis icd code from our data source-->
   <option value="453">Diabetes</option>
   <option value="111">Other</option>
   </select><br>
<input type="submit" value="Add Patient">
<input type="reset" value="Clear">
</form>

<p>
 <?php
   $pname=$_POST['pname'];

echo "Patient Name: $pname ";
?> 
</p>

 </body>
</html>